The Oxford Knee Score is a reliable predictor of patients in a health state worse than death and awaiting total knee arthroplasty

Socioeconomic deprivation is associated with worse health-related quality of life and greater opioid analgesia use while waiting for hip and knee arthroplasty

Aims

The overall aim of this study was to determine the impact of deprivation with regard to quality of life, demographics, joint-specific function, attendances for unscheduled care, opioid and antidepressant use, having surgery elsewhere, and waiting times for surgery on patients awaiting total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

Postal surveys were sent to 1,001 patients on the waiting list for THA or TKA in a single Northern Ireland NHS Trust, which consisted of the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee Scores. Electronic records determined prescriptions since addition to the waiting list and out-of-hour GP and emergency department attendances. Deprivation quintiles were determined by the Northern Ireland Multiple Deprivation Measure 2017 using postcodes of home addresses.

Results

Overall, 707 postal surveys were returned, of which 277 (39.2%) reported negative "worse than death" EQ-5D scores and 219 (21.9%) reported the consumption of strong opioids. Those from the least deprived quintile 5 had a significantly better EQ-5D index (median 0.223 (interquartile range (IQR) -0.080 to 0.503) compared to those in the most deprived quintiles 1 (median 0.049 (IQR -0.199 to 0.242), p = 0.004), 2 (median 0.076 (IQR -0.160 to 0.277; p = 0.010), and 3 (median 0.076 (IQR-0.153 to 0.301; p = 0.010). Opioid use was significantly greater in the most deprived quintile 1 compared to all other quintiles (45/146 (30.8%) vs 174/809 (21.5%); odds ratio 1.74 (95% confidence interval 1.18 to 2.57; p = 0.005).

Conclusion

More deprived patients have worse health-related quality of life and greater opioid use while waiting for THA and TKA than more affluent patients. For patients awaiting surgery, more information and alternative treatment options should be available.

Editorial: factors influencing the outcome of total hip and knee arthroplasty

BACKGROUND

Total hip and knee arthroplasty for end stage arthritis are among the most cost-effective interventions available in all of medicine. Success of hip and knee arthroplasties is not universal and approximately one in ten patients are not satisfied with their arthroplasty and 10 to 34% of patients have an unfavourable long term pain outcome. The aim of this edition of Arthroplasty was to identify factors associated with: (1) poor joint specific outcome, (2) poor health related quality of life outcome and (3) dissatisfaction following total hip and knee arthroplasty.

METHODS

The scope was deliberately broad to identify factors (known and unknown) that influence outcome of total hip and knee arthroplasty, and of 40 submissions, eight were selected for this special edition after peer review.

RESULTS

Many of the included studies reported subjective patient reported outcome measures as their key outcomes but other objective measures such as muscle mass, timed Up-and-Go test, kneeling ability and postoperative pain are also featured. Some studies involved a focus on early rehabilitation after surgery (ERAS) principles and how to optimise pre-rehabilitation and reduce length of hospital stay readmission and reoperation. The effect of metal allergy and drain usage on outcomes is also explored. A variety of methodologies have been used including one randomised control trial, some machine learning and three systematic reviews investigating the effect of metal allergy on outcomes, associations with postoperative pain and the effect of patella resurfacing.

CONCLUSION

This special edition has advanced our knowledge of factors influencing to the outcome of hip and knee arthroplasty but has also identified several areas of research that need to be addressed to improve the outcomes of our patients.

Current evidence does not support the routine use of cognitive behavioural therapy in total knee arthroplasty: A systematic review

Background

There is a significant dissatisfaction rate in patients undergoing total knee arthroplasty (TKA), and poor mental health in patients is increasingly recognized as a major contributor to dissatisfaction. The aim was to review the effectiveness of cognitive behavioural therapy (CBT) in improving pain and functional outcomes of patients undergoing TKA and highlight important aspects that may be crucial for improvement.

Methods

A systematic search was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were included if they were randomized control trials that included patients undergoing unilateral or bilateral TKA, with CBT as an intervention compared against usual care, and reported outcomes in pain, knee function and any psychological outcomes as measured.

Results

Eight RCTs were selected which included 683 participants. The timings of CBT delivery, profiles of therapists, and outcome measures reported varied across the studies. Overall, 3 studies reported significant improvement in pain outcomes, 3 studies reported significant improvement in functional outcomes and 5 studies reported significant improvements in psychological outcomes.

Conclusion

Current evidence does not support the efficacy of CBT as current literature is too heterogenous. Further studies with homogenous CBT methods are required to further ascertain the true relationship between CBT and postoperative outcomes of TKA. Future studies should consider the points set out in this review, such as the importance of revisiting CBTskills, providing individualized therapy, having a supervisory team to support the fidelity of interventions, and identifying which group of patients would best benefit from CBT.

Oxford hip and knee scores deteriorate in patients awaiting lower limb arthroplasty during the COVID-19 pandemic and predict a health state 'worse than death'

The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state 'worse than death' (WTD). In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L. A total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity). OHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data.